Sex-Specific Outcome Profiles in Abdominal and Perineal Rectal Prolapse Repair

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The study evaluates sex-specific functional outcomes, recurrence, and complications following abdominal and perineal rectal prolapse repair. Methods This retrospective single-center cohort included adults undergoing full-thickness rectal prolapse surgery between 2013 and 2023 with 12- and 36-month follow-up. Quality of life (EQ-VAS), constipation (CCCS), and fecal incontinence (Wexner) were assessed preoperatively and postoperatively. Outcomes were compared between women and men overall and stratified by operative approach. Recurrence and complications (Clavien-Dindo) were analyzed using Fisher’s exact tests; exploratory univariate logistic regression was performed for recurrence. Results A total of 180 patients were analyzed (162 women, 18 men). Men were younger and more often treated with an abdominal approach. Baseline fecal incontinence was more severe in women, while baseline quality of life and constipation were comparable. Surgery significantly improved all functional domains at 1 and 3 years (all p < 0.001). Change-from-baseline effects did not differ significantly by sex, including within approach strategies. Recurrence and complication rates were low and did not differ significantly between sexes. Conclusion Functional improvement after rectal prolapse repair was substantial in both sexes, without statistically significant sex-specific differences in treatment effect, recurrence, or complications. Rectal prolapse VMR rectopexy Altemeier Delorme quality of life Figures Figure 1 Figure 2 Introduction Complete rectal prolapse (RP) is defined as a protrusion of rectum through the anus. Associated symptoms commonly include concomitant fecal incontinence and constipation, mucous and bloody discharge, and incomplete evacuation. Rectal prolapse has substantial social impact by diminishing quality of life and contributing to social isolation. RP is 6–9 times more common in women than in men [ 1 ]. In men, RP tends to occur at a much younger age (< 40 years) and is frequently associated with autism spectrum disorder and other psychiatric conditions [ 2 , 3 ]. It has also been linked in the literature to genetic factors [ 4 ] and parasitic diseases in childhood [ 5 ], although its exact etiology remains unknown [ 6 ]. In contrast, RP in women typically presents in older adults, with peak prevalence in the seventh decade of life, and is often attributed to multiparity, instrumental delivery, or prior hysterectomy, frequently coexisting with pelvic organ prolapse [ 7 ]. The only definitive treatment for rectal prolapse is surgical intervention [ 8 ]. Broadly, two principal operative approaches are employed: the abdominal approach, which is associated with lower recurrence rates and improved quality of life; and the perineal approach, typically reserved for older patients with frailty syndrome who are poor candidates for general anesthesia [ 9 ]. The most commonly utilized procedures include the Delorme and Altemeier techniques within the perineal approach, and ventral mesh rectopexy (VMR) and resection rectopexy within the abdominal approach [ 2 ].” Despite the distinct underlying etiologies of RP, the same surgical treatment algorithms are applied in both men and women. Currently, no guidelines propose a sex-specific management strategy for RP. According to a recent systematic review published in Colorectal Disease [ 6 ], the available evidence is insufficient to recommend a particular surgical approach based on recurrence rates or functional outcomes. The authors highlight the need for further studies to determine the optimal operative strategy for rectal prolapse in men. The aim of this study is to present the outcomes of a single-center cohort and to contribute data that may inform future management strategies for rectal prolapse across genders. Methods - Patients Between 2013 and 2023, 196 surgically treated patients were evaluated. The inclusion criteria were patients over 18 years of age presenting with full-thickness rectal prolapse. The study cohort included patients with both primary and recurrent prolapse (defined as the reappearance of external full-thickness prolapse). The recurrent group included patients presenting with either a first recurrence or multiple previous recurrences. Patients lost to follow-up (n = 16) were excluded from the study. Consequently, a total of 180 patients were included in the final analysis. The cohort consisted of F = 162 females and M = 18 males, with a median age of 68 years. All patients underwent surgery performed by a single specialist team across multiple hospitals in Poland. The primary centers included the Warsaw Center for Proctology, Wolomin District Hospital, and the Maria Sklodowska-Curie District Hospital in Ostrow Mazowiecka. The research employed a retrospective methodology and was approved by the bioethics committee of Regional Medical Chamber in Warsaw. Informed consent was obtained and all participants retained the right to opt out of the study. - Data collection Functional outcomes and recurrences were evaluated using validated questionnaires preoperatively and during follow-up assessments conducted at 12 and 36 months postoperatively. Data collection utilized follow-up visits or structured telephone surveys. Demographic variables recorded for analysis included age, sex, and body mass index. The patient's overall health status was assessed using the American Society of Anesthesiologists (ASA) physical status classification. The history of prior interventions was documented, noting the number and type of all previous procedures for rectal prolapse. Occupations were categorized as either manual or non-manual. Demographic data are summarized in Table 1 . Table 1 Demographic data Sex Number of patients Median age Median BMI (kg/m^2) Median ASA Manual/non-manual work Primary/ recurrent RP Female 162 70 26,1 2 48% manual 78% primary Male 18 38 24,5 1 78% manual 100% primary Functional outcomes were evaluated using validated, quantitative scoring systems. Quality of life (QoL) was measured using the EuroQol Visual Analogue Scale (EQ-VAS) score. The severity of constipation was assessed using the Cleveland Clinic Constipation Score (CCCS), and the severity of fecal incontinence was measured by the Cleveland Clinic Fecal Incontinence Severity Scoring System (Wexner score). Primary surgical outcomes included operative time, 30-day mortality, and the rate of recurrence. Postoperative complications were classified according to the Clavien-Dindo classification system. Recurrence was defined as the reappearance of external full-thickness prolapse. - Principles of surgical techniques and postoperative care All surgeries were stratified by patient sex and by approach (abdominal or perineal). The male cohort (M = 18) comprised Mn1 = 14 abdominal and Mn2 = 4 perineal procedures, while the female cohort (F = 162) comprised Fn1 = 70 abdominal and Fn2 = 92 perineal procedures. Figures 1 and 2 illustrate this distribution. The preoperative protocol mandated a single prophylactic dose of intravenous antibiotics. This regimen consisted of cefazolin (2 g), with an additional dose of metronidazole (500 mg) administered specifically for patients undergoing resectional procedures. Bowel preparation involved administering a double enema at 16:00 and 20:00 on the day preceding the operation. The abdominal approach procedures encompassed in total 45 ventral mesh rectopexies and 39 resection rectopexies (Frykman-Goldberg procedures). In cases of concurrent pelvic organ prolapse in women, sacrocolpopexy or sacrohysteropexy was performed concurrently (n = 14). For the ventral mesh rectopexy, a B-shaped implant was utilized. The mesh was fixed in a diamond-shaped configuration to the anterior rectal wall using 5–7 3/0 absorbable sutures. The cephalad end of the mesh was secured to the anterior longitudinal ligament below the sacral promontory using 3 2/0 non-absorbable sutures. The mesh materials employed included synthetic polypropylene (Optilene® Mesh), bioresorbable (Phasix™ Mesh), or porcine-derived (XenMatrix™) materials. For the resection rectopexy, the colonic anastomosis was performed using a 33-mm circular stapler. The subsequent rectopexy itself was typically secured with 3–4 2/0 interrupted non-absorbable sutures. No mesh, drain, or protective ileostomy was utilized in the resection rectopexy procedure. The perineal approach consisted of the Delorme procedure (n = 11) and the Altemeier procedure (n = 85). The choice between them was guided by the extent of the prolapse: the Delorme procedure was reserved for prolapses measuring less than 8 cm with a high take-off, whereas the Altemeier procedure was the preferred technique for prolapses exceeding 8 cm or those with a low take-off. In the Delorme procedure, muscle plication was achieved using eight separate absorbable sutures, and the mucosal anastomosis required approximately 24 3/0 absorbable sutures. For the Altemeier procedure, the anastomosis was constructed in a single-layer, interrupted fashion, typically requiring an average of 24 absorbable 3/0 sutures to complete. In instances where a wide pelvic hiatus was observed, posterior levatoroplasty was performed as a supplementary measure for both procedures. This plication was achieved through the same incision for the Altemeier procedure and a separate incision for the Delorme procedure. Postoperative care was standardized, consisting of appropriate analgesic therapy, early mobilization, and the intake of fluids and a light meal on the first postoperative day, along with 15 ml of lactulose daily. No prolonged antibiotic therapy was employed. Follow-up visits were scheduled at 1 week, 6 weeks, one year, and three years after the procedure. - Statistical analysis Patients were grouped according to sex (female vs male). Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data are presented as mean ± standard deviation (SD), whereas non-normally distributed variables are reported as medians with interquartile ranges (IQR). Baseline characteristics were compared between women and men using independent-sample t-tests or Mann-Whitney U tests for continuous variables, as appropriate. Categorical variables were compared using Fisher’s exact test due to small group sizes. Changes in quality of life, constipation, and fecal incontinence scores before and after surgery were analyzed using paired t-tests or Wilcoxon signed-rank tests, depending on data distribution. Sex-specific treatment effects were evaluated by comparing delta values (postoperative minus preoperative scores) between women and men using independent-sample t-tests or Mann-Whitney U tests, as appropriate. Recurrence rates were compared using Fisher’s exact test. Exploratory univariate logistic regression analyses were performed to estimate odds ratios (ORs) with corresponding 95% confidence intervals (CIs) for recurrence. All statistical tests were two-sided. A p-value < 0.05 was considered statistically significant. Statistical analyses were performed using R software (version 4.5.1; R Core Team 2025). Results a) Functional outcomes Overall: women vs men At baseline, quality of life and constipation were comparable between sexes, while fecal incontinence was more severe in women (Table 2 ; Supplementary Table S1 ). Surgery was associated with significant improvements in quality of life, constipation, and fecal incontinence at follow-up in both sexes ( Supplementary Table S1 ). Improvements did not differ statistically significantly between women and men at either follow-up interval, indicating broadly similar functional improvement across sexes ( Supplementary Table S1 ). Stratified by operative approach: women vs men After stratification by abdominal versus perineal approach, there were no statistically significant sex differences in baseline functional measures or in change-from-baseline effects within either approach ( Supplementary Table S2 ). These subgroup comparisons should be interpreted cautiously for perineal repairs given the small male sample in perineal approach group. b) Recurrence rates Overall: women vs men Overall recurrence rates did not differ significantly by sex (Table 2 ; Supplementary Table S1 ). In exploratory univariate logistic regression, neither sex nor age demonstrated a statistically significant association with recurrence ( Supplementary Table S5 ). Stratified by operative approach: women vs men Within both abdominal and perineal approaches, recurrence rates did not differ significantly between women and men ( Supplementary Table S3 ). c) Complications Overall: women vs men Postoperative complications were uncommon and did not differ significantly by sex (Table 2 ). Most of the complications were minor, according to Clavien-Dindo classification ( Supplementary Table S0 ). Stratified by operative approach: women vs men Complication rates remained low within both abdominal and perineal groups and did not demonstrate a statistically significant sex-specific pattern ( Supplementary Table S4 ). Table 2 Patient characteristics, operative approach, and outcomes by sex. Data are presented as median (IQR) for continuous variables and n (%) for categorical variables. P-values reflect between-sex comparisons at baseline or for categorical outcomes (Mann-Whitney U or Fisher’s exact test). Variable Women Men p-value (between sexes) Demographics and operative approach Patients, n 162 18 Age, median (IQR) 70 (30) 38 (33.8) < 0.001 Approach: abdominal, n (%) 70 (43.2%) 14 (77.8%) Approach: perineal, n (%) 92 (56.8%) 4 (22.2%) Functional outcomes QoL preoperative, median (IQR) 50 (35) 35 (20) 0.081 QoL 1 year, median (IQR) 78 (40) 77.5 (18.5) QoL 3 years, median (IQR) 70 (40) 76 (30) Constipation (CCCS) preoperative, median (IQR) 13 (12) 14 (10.8) 0.506 Constipation (CCCS) 1 year, median (IQR) 3.5 (6) 4 (6) Constipation (CCCS) 3 years, median (IQR) 3 (6) 5 (4.5) Fecal incontinence (Wexner) preoperative, median (IQR) 14 (8) 6 (13.8) 0.045 Fecal incontinence (Wexner) 1 year, median (IQR) 5 (11) 0 (7.8) Fecal incontinence (Wexner) 3 years, median (IQR) 4 (10) 0 (4) Clinical outcomes Recurrence, n (%) 32 (19.8%) 2 (11.1%) 0.532 Any complication, n (%) 8 (4.9%) 1 (5.6%) 1.000 Supplementary Table S0. Complications Sex Complication Implied management Clavien-Dindo grade woman Anastomotic leak with sepsis Reoperation with stoma creation IIIb woman Upper GI bleeding Endoscopy IIIa woman Minor anastomotic leak Antibiotics alone II woman Wound seroma Bedside management I woman Pulmonary embolism Transferred to internal medicine, therapeutic anticoagulation; eventually death V woman Massive presacral plexus bleeding Blood transfusion II woman Wound hematoma Bedside management I woman Minor suture line bleeding Conservative management I man Wound dehiscence Reoperation with resuturing IIIb Supplementary Table S1. Overall statistical comparisons (sex differences, paired changes) Between-sex comparisons (overall) Comparison p-value Age (Mann-Whitney) < 0.001 Baseline QoL (Mann-Whitney) 0.081 Baseline Constipation (Mann-Whitney) 0.506 Baseline Incontinence (Mann-Whitney) 0.045 Delta QoL 1y (Mann-Whitney) 0.054 Delta QoL 3y (Mann-Whitney) 0.273 Delta Constipation 1y (Mann-Whitney) 0.774 Delta Constipation 3y (Mann-Whitney) 0.560 Delta Incontinence 1y (Mann-Whitney) 0.077 Delta Incontinence 3y (Mann-Whitney) 0.073 Recurrence by sex (Fisher) 0.532 Within-patient paired comparisons (overall) Comparison p-value QoL: pre vs 1y < 0.001 QoL: pre vs 3y < 0.001 Constipation: pre vs 1y < 0.001 Constipation: pre vs 3y < 0.001 Incontinence: pre vs 1y < 0.001 Incontinence: pre vs 3y < 0.001 Supplementary Table S2. Approach-stratified between-sex comparisons (p-values). Approach p (age) p (QoL pre) p (CCCS pre) p (Wexner pre) p (ΔQoL 1y) p (ΔQoL 3y) p (ΔCCCS 1y) p (ΔCCCS 3y) p (ΔWexner 1y) p (ΔWexner 3y) abdominal 0.052 0.125 0.862 0.191 0.139 0.717 0.670 0.626 0.465 0.138 perineal 0.158 0.271 0.696 0.818 0.392 0.290 0.767 0.355 0.114 0.476 Supplementary Table S3. Recurrence by sex within operative approach. Approach Women, n/N (%) Men, n/N (%) p-value (Fisher) abdominal 9/70 (12.9%) 1/14 (7.1%) 1.000 perineal 23/92 (25.0%) 1/4 (25.0%) 1.000 Supplementary Table S4. Any postoperative complication by sex within operative approach. Approach Women, n/N (%) Men, n/N (%) p-value (Fisher) abdominal 3/70 (4.3%) 1/14 (7.1%) 0.525 perineal 5/92 (5.4%) 0/4 (0.0%) 1.000 Supplementary Table S5. Exploratory univariate logistic regression for recurrence (odds ratios and 95% CIs). Predictor Contrast (reference) Odds ratio (OR) 95% CI (profile) - lower 95% CI (profile) - upper 95% CI (Wald) - lower 95% CI (Wald) - upper Sex Male vs Female 0,508 0,078 1,909 0,111 2,322 Age Per 1-year increase 1,009 0,991 1,028 0,991 1,027 Discussion Our findings indicate that recurrence rates for rectal prolapse are lower in men than in women; however, this difference did not reach statistical significance. While this disparity might initially be attributed to the surgical approach - given that the abdominal technique is associated with lower recurrence [ 2 ] - the data suggests a more complex etiology. Although a higher proportion of male patients undergo abdominal surgery, the increased success rate cannot be explained by the surgical method alone. Notably, when comparing abdominal approaches across genders, the procedure yields superior outcomes in men compared to women; again the difference between sexes within either abdominal or perineal repairs is not statistically significant, indicating that any apparent sex-related advantage should be interpreted as descriptive rather than confirmatory. This reason is likely multifactorial. Male patients presenting with rectal prolapse (RP) tend to be younger, often correlating with a lower ASA physical status, superior muscle tone, and higher collagen quality [ 10 ]. Furthermore, anatomical differences play a role - the narrower male pelvis may inherently provide more structural support, thereby decreasing the risk of recurrence. Notably, even the higher prevalence of manual work among men does not offset these protective physiological factors. Consequently, our study suggests that gender and surgical approach should be regarded as two independent variables contributing to the slightly lower recurrence rates observed in male RP repair. However, it is important to note that recent literature presents conflicting evidence regarding specific techniques. According to a 2019 systematic review [ 11 ], VMR may actually be associated with higher recurrence rates in men than in women. The authors suggest that the narrow male pelvis may potentially impede surgical manipulation. This technical difficulty, particularly for less experienced surgeons, may ultimately compromise the efficacy of the repair and lead to higher failure rates. Regarding quality of life and postoperative constipation, our study found no significant gender-based differences. This suggests that the resolution of constipation is secondary to a surgical approach rather than sex-specific factors. As highlighted in clinical guidance, VMR is typically favored in patients with obstructed defecation syndrome, whereas resection rectopexy is reserved for those with slow-transit constipation [ 12 ]. Ultimately, appropriate preoperative evaluation and intraoperative decision-making serve as the primary drivers of success in achieving constipation relief, ensuring that the intervention is tailored to the patient’s specific pathophysiology rather than their gender. A key differentiating patient-reported outcome measure between the genders is fecal incontinence (FI), which was more severe in women preoperatively. This difference likely reflects distinct underlying etiologies; in many elderly women, rectal prolapse (RP) is secondary to a chronically lax sphincter and a weakened pelvic floor. Conversely, in the majority of men, incontinence is most likely a secondary consequence of chronic sphincter stretching and pudendal nerve traction caused by the rectal prolapse (RP) itself [ 13 ]. Consequently, one can argue, that FI remission is often complete in men once the primary driver - the prolapse - is surgically corrected. In women, however, postoperative continence often returns to the diminished baseline levels present prior to the onset of RP. It is important to emphasize that prolonged RP can induce irreversible FI even in patients with previously preserved continence. Therefore, surgical repair should not be excessively delayed [ 14 ]. Another important point to consider is the sexual function prior to and following the surgical intervention. Historically, traditional teaching advocated perineal approach in men to preserve sexual function [ 15 ]. The rationale was that an abdominal approach may cause inadvertent injury to the hypogastric nerves, inferior hypogastric plexus, pelvic plexus, or periprostatic plexus during rectal mobilization. [ 16 ]. However, contemporary evidence has challenged this paradigm. Fagan et al. [ 6 ] noted that there is insufficient high-quality data to recommend a perineal approach solely for the preservation of sexual function. In the present study, while a formal, validated sexual function assessment was not conducted, no patients reported de novo sexual dysfunction during follow-up, regardless of whether they underwent ventral mesh rectopexy (VMR) or resection rectopexy. Postoperative complications were uncommon overall and did not differ significantly by sex, including after stratification by operative approach. Given the small male subgroup and low event counts, the analysis is best interpreted as reassuring but exploratory with respect to sex-specific complication risk. Limitations: This study is subject to several limitations. First, the data represent a retrospective, single-center experience involving a single surgical team, which may limit the generalizability of the results. Furthermore, treatment allocation was not randomized; the choice between a perineal or abdominal approach was based on patient comorbidities and surgical risk profile. While the cohort includes a relatively small number of patients, this reflects the low epidemiological prevalence of rectal prolapse (especially in men). Additionally, the study population is exclusively of Polish ethnicity. This is a relevant factor, as Vogel et al. [ 10 ] have demonstrated significant disparities in rectal prolapse occurrence across different ethnic groups. Technical variability must also be considered, as three different types of mesh were utilized across the study period. Finally, the recurrence rates may be underrated, because the recurrences may occur even after 10 years after the surgery [ 17 ]. Conclusions In this single-center study, rectal prolapse repair was associated with improvements in quality of life, constipation, and fecal incontinence at 1 and 3 years. Although men presented at a younger age and exhibited a different baseline continence profile, postoperative functional gains, recurrence, and complication rates did not reach statistical difference between sexes, both overall and after stratification by operative approach. These findings support the continued use of established, risk-guided surgical algorithms in both sexes while emphasizing that the current evidence in men remains limited by small sample sizes. Larger multicenter studies are needed to clarify whether subtle sex-specific predictors of recurrence or functional recovery exist and to suggest any future sex-tailored management strategy. Declarations No funding was received to assist with the preparation of this manuscript. The authors have no competing interests to declare that are relevant to the content of this article. Author Contribution PC collected the data and served as the primary surgeon. SR conceptualized the study as well as performed data extraction, conducted the formal analysis, and drafted the manuscript. PC validated the data and contributed to data interpretation. MK provided supervision. All authors reviewed and approved the final manuscript. Acknowledgement The authors thank Grzegorz Rzadkowski for his assistance with the statistical analysis. Data Availability All data generated or analyzed during this study are included in this published article. Further information can be obtained from the corresponding author on reasonable request. References Riansuwan W, Hull TL, Bast J, Hammel JP, Church JM (2010) Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World J Surg 34(5):1116–1122. 10.1007/s00268-010-0429-0 Bordeianou L, Paquette I, Johnson E, Holubar SD, Gaertner W, Feingold DL et al (2017) Clinical practice guidelines for the treatment of rectal prolapse. 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J Korean Soc Coloproctol 16(4):223–230. 10.3393/jksc.2000.16.4.223 Cunin D, Siproudhis L, Desfourneaux V, Berkelmans I, Meunier B, Bretagne JF et al (2013) No surgery for full-thickness rectal prolapse: what happens with continence? World J Surg 37(6):1297–1302. 10.1007/s00268-013-1967-z Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Simeone DM, Upchurch GR (eds) (2012) Greenfield's surgery: scientific principles and practice, 5th edn. Lippincott Williams & Wilkins, Philadelphia (PA) Giglia MD, Stein SL (2019) Overlooked long-term complications of colorectal surgery. Clin Colon Rectal Surg 32(3):204–211. 10.1055/s-0038-1677027 Raftopoulos Y, Senagore AJ, Di Giuro G, Bergamaschi R et al (2005) Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data. Dis Colon Rectum 48(6):1200–1206. 10.1007/s10350-004-0948-6 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor assigned by journal 18 Jan, 2026 Submission checks completed at journal 18 Jan, 2026 First submitted to journal 18 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8630421","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578979348,"identity":"49c0abff-42a2-41c4-a177-3a32ded0a8df","order_by":0,"name":"Przemyslaw Ciesielski","email":"","orcid":"","institution":"\tWarsaw Proctology Centre, St. Elizabeth’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Przemyslaw","middleName":"","lastName":"Ciesielski","suffix":""},{"id":578979349,"identity":"a1ab6d67-92ea-4a3c-a40b-bfc8cc73b7a8","order_by":1,"name":"Stanislaw Rzadkowski","email":"data:image/png;base64,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","orcid":"","institution":"\tDepartment of General Surgery, John Paul II Western Hospital","correspondingAuthor":true,"prefix":"","firstName":"Stanislaw","middleName":"","lastName":"Rzadkowski","suffix":""},{"id":578979352,"identity":"b78f17ee-4271-41c9-a083-d9ec13943f27","order_by":2,"name":"Malgorzata Kolodziejczak","email":"","orcid":"","institution":"\tWarsaw Proctology Centre, St. Elizabeth’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Malgorzata","middleName":"","lastName":"Kolodziejczak","suffix":""}],"badges":[],"createdAt":"2026-01-18 09:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8630421/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8630421/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101073607,"identity":"02fe192f-85f9-4108-be4a-d40e8058428e","added_by":"auto","created_at":"2026-01-25 10:17:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72597,"visible":true,"origin":"","legend":"","description":"","filename":"SexSpecificOutcomeProfilesinAbdominalandPerinealRectalProlapseRepair.docx","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/1cc22be3894c7f8207c17e12.docx"},{"id":101205651,"identity":"37b5c18f-8445-4c79-90c6-000f550eaa1e","added_by":"auto","created_at":"2026-01-27 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10:17:10","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85510,"visible":true,"origin":"","legend":"","description":"","filename":"7de590e0d4d040e4aa628563a625bc431structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/adca1d9146782ef30e2efdf3.xml"},{"id":101205840,"identity":"e32d7d50-f359-425d-b249-e1d4ff900c70","added_by":"auto","created_at":"2026-01-27 09:50:22","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96830,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/8efe6ad6a55b854059d39c27.html"},{"id":101073606,"identity":"f957c56e-c885-43a0-8693-e0bfb416969d","added_by":"auto","created_at":"2026-01-25 10:17:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109221,"visible":true,"origin":"","legend":"\u003cp\u003eSurgeries in male patients\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/9c1be61d7981aa4849098b70.jpg"},{"id":101073613,"identity":"58152404-03f1-4708-a429-f0af6456d37b","added_by":"auto","created_at":"2026-01-25 10:17:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":116046,"visible":true,"origin":"","legend":"\u003cp\u003eSurgeries in female patients\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/0cc54b226189f7c700366703.jpg"},{"id":101296881,"identity":"41ae2059-2a12-4a02-921f-32b15bdd0d29","added_by":"auto","created_at":"2026-01-28 09:22:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1259733,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8630421/v1/956ef6c7-5d84-47f9-b41f-bb9056f049a5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sex-Specific Outcome Profiles in Abdominal and Perineal Rectal Prolapse Repair","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplete rectal prolapse (RP) is defined as a protrusion of rectum through the anus. Associated symptoms commonly include concomitant fecal incontinence and constipation, mucous and bloody discharge, and incomplete evacuation. Rectal prolapse has substantial social impact by diminishing quality of life and contributing to social isolation.\u003c/p\u003e \u003cp\u003eRP is 6\u0026ndash;9 times more common in women than in men [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In men, RP tends to occur at a much younger age (\u0026lt;\u0026thinsp;40 years) and is frequently associated with autism spectrum disorder and other psychiatric conditions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It has also been linked in the literature to genetic factors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and parasitic diseases in childhood [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], although its exact etiology remains unknown [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In contrast, RP in women typically presents in older adults, with peak prevalence in the seventh decade of life, and is often attributed to multiparity, instrumental delivery, or prior hysterectomy, frequently coexisting with pelvic organ prolapse [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe only definitive treatment for rectal prolapse is surgical intervention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Broadly, two principal operative approaches are employed: the abdominal approach, which is associated with lower recurrence rates and improved quality of life; and the perineal approach, typically reserved for older patients with frailty syndrome who are poor candidates for general anesthesia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The most commonly utilized procedures include the Delorme and Altemeier techniques within the perineal approach, and ventral mesh rectopexy (VMR) and resection rectopexy within the abdominal approach [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u0026rdquo;\u003c/p\u003e \u003cp\u003eDespite the distinct underlying etiologies of RP, the same surgical treatment algorithms are applied in both men and women. Currently, no guidelines propose a sex-specific management strategy for RP. According to a recent systematic review published in Colorectal Disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the available evidence is insufficient to recommend a particular surgical approach based on recurrence rates or functional outcomes. The authors highlight the need for further studies to determine the optimal operative strategy for rectal prolapse in men.\u003c/p\u003e \u003cp\u003eThe aim of this study is to present the outcomes of a single-center cohort and to contribute data that may inform future management strategies for rectal prolapse across genders.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e- Patients\u003c/h3\u003e\n\u003cp\u003eBetween 2013 and 2023, 196 surgically treated patients were evaluated. The inclusion criteria were patients over 18 years of age presenting with full-thickness rectal prolapse. The study cohort included patients with both primary and recurrent prolapse (defined as the reappearance of external full-thickness prolapse). The recurrent group included patients presenting with either a first recurrence or multiple previous recurrences.\u003c/p\u003e \u003cp\u003ePatients lost to follow-up (n\u0026thinsp;=\u0026thinsp;16) were excluded from the study. Consequently, a total of 180 patients were included in the final analysis. The cohort consisted of F\u0026thinsp;=\u0026thinsp;162 females and M\u0026thinsp;=\u0026thinsp;18 males, with a median age of 68 years.\u003c/p\u003e \u003cp\u003eAll patients underwent surgery performed by a single specialist team across multiple hospitals in Poland. The primary centers included the Warsaw Center for Proctology, Wolomin District Hospital, and the Maria Sklodowska-Curie District Hospital in Ostrow Mazowiecka.\u003c/p\u003e \u003cp\u003e The research employed a retrospective methodology and was approved by the bioethics committee of Regional Medical Chamber in Warsaw. Informed consent was obtained and all participants retained the right to opt out of the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e- Data collection\u003c/h2\u003e \u003cp\u003eFunctional outcomes and recurrences were evaluated using validated questionnaires preoperatively and during follow-up assessments conducted at 12 and 36 months postoperatively. Data collection utilized follow-up visits or structured telephone surveys.\u003c/p\u003e \u003cp\u003eDemographic variables recorded for analysis included age, sex, and body mass index. The patient's overall health status was assessed using the American Society of Anesthesiologists (ASA) physical status classification. The history of prior interventions was documented, noting the number and type of all previous procedures for rectal prolapse. Occupations were categorized as either manual or non-manual. Demographic data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian BMI (kg/m^2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian ASA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eManual/non-manual work\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary/ recurrent RP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48% manual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78% primary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78% manual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100% primary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFunctional outcomes were evaluated using validated, quantitative scoring systems. Quality of life (QoL) was measured using the EuroQol Visual Analogue Scale (EQ-VAS) score. The severity of constipation was assessed using the Cleveland Clinic Constipation Score (CCCS), and the severity of fecal incontinence was measured by the Cleveland Clinic Fecal Incontinence Severity Scoring System (Wexner score).\u003c/p\u003e \u003cp\u003ePrimary surgical outcomes included operative time, 30-day mortality, and the rate of recurrence. Postoperative complications were classified according to the Clavien-Dindo classification system. Recurrence was defined as the reappearance of external full-thickness prolapse.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e- Principles of surgical techniques and postoperative care\u003c/h3\u003e\n\u003cp\u003eAll surgeries were stratified by patient sex and by approach (abdominal or perineal). The male cohort (M\u0026thinsp;=\u0026thinsp;18) comprised Mn1\u0026thinsp;=\u0026thinsp;14 abdominal and Mn2\u0026thinsp;=\u0026thinsp;4 perineal procedures, while the female cohort (F\u0026thinsp;=\u0026thinsp;162) comprised Fn1\u0026thinsp;=\u0026thinsp;70 abdominal and Fn2\u0026thinsp;=\u0026thinsp;92 perineal procedures. Figures\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrate this distribution.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe preoperative protocol mandated a single prophylactic dose of intravenous antibiotics. This regimen consisted of cefazolin (2 g), with an additional dose of metronidazole (500 mg) administered specifically for patients undergoing resectional procedures. Bowel preparation involved administering a double enema at 16:00 and 20:00 on the day preceding the operation.\u003c/p\u003e \u003cp\u003eThe abdominal approach procedures encompassed in total 45 ventral mesh rectopexies and 39 resection rectopexies (Frykman-Goldberg procedures). In cases of concurrent pelvic organ prolapse in women, sacrocolpopexy or sacrohysteropexy was performed concurrently (n\u0026thinsp;=\u0026thinsp;14).\u003c/p\u003e \u003cp\u003eFor the ventral mesh rectopexy, a B-shaped implant was utilized. The mesh was fixed in a diamond-shaped configuration to the anterior rectal wall using 5\u0026ndash;7 3/0 absorbable sutures. The cephalad end of the mesh was secured to the anterior longitudinal ligament below the sacral promontory using 3 2/0 non-absorbable sutures. The mesh materials employed included synthetic polypropylene (Optilene\u0026reg; Mesh), bioresorbable (Phasix\u0026trade; Mesh), or porcine-derived (XenMatrix\u0026trade;) materials. For the resection rectopexy, the colonic anastomosis was performed using a 33-mm circular stapler. The subsequent rectopexy itself was typically secured with 3\u0026ndash;4 2/0 interrupted non-absorbable sutures. No mesh, drain, or protective ileostomy was utilized in the resection rectopexy procedure.\u003c/p\u003e \u003cp\u003eThe perineal approach consisted of the Delorme procedure (n\u0026thinsp;=\u0026thinsp;11) and the Altemeier procedure (n\u0026thinsp;=\u0026thinsp;85). The choice between them was guided by the extent of the prolapse: the Delorme procedure was reserved for prolapses measuring less than 8 cm with a high take-off, whereas the Altemeier procedure was the preferred technique for prolapses exceeding 8 cm or those with a low take-off.\u003c/p\u003e \u003cp\u003eIn the Delorme procedure, muscle plication was achieved using eight separate absorbable sutures, and the mucosal anastomosis required approximately 24 3/0 absorbable sutures. For the Altemeier procedure, the anastomosis was constructed in a single-layer, interrupted fashion, typically requiring an average of 24 absorbable 3/0 sutures to complete. In instances where a wide pelvic hiatus was observed, posterior levatoroplasty was performed as a supplementary measure for both procedures. This plication was achieved through the same incision for the Altemeier procedure and a separate incision for the Delorme procedure.\u003c/p\u003e \u003cp\u003ePostoperative care was standardized, consisting of appropriate analgesic therapy, early mobilization, and the intake of fluids and a light meal on the first postoperative day, along with 15 ml of lactulose daily. No prolonged antibiotic therapy was employed. Follow-up visits were scheduled at 1 week, 6 weeks, one year, and three years after the procedure.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e- Statistical analysis\u003c/h2\u003e \u003cp\u003ePatients were grouped according to sex (female vs male). Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), whereas non-normally distributed variables are reported as medians with interquartile ranges (IQR).\u003c/p\u003e \u003cp\u003eBaseline characteristics were compared between women and men using independent-sample t-tests or Mann-Whitney U tests for continuous variables, as appropriate. Categorical variables were compared using Fisher\u0026rsquo;s exact test due to small group sizes.\u003c/p\u003e \u003cp\u003eChanges in quality of life, constipation, and fecal incontinence scores before and after surgery were analyzed using paired t-tests or Wilcoxon signed-rank tests, depending on data distribution.\u003c/p\u003e \u003cp\u003eSex-specific treatment effects were evaluated by comparing delta values (postoperative minus preoperative scores) between women and men using independent-sample t-tests or Mann-Whitney U tests, as appropriate.\u003c/p\u003e \u003cp\u003eRecurrence rates were compared using Fisher\u0026rsquo;s exact test. Exploratory univariate logistic regression analyses were performed to estimate odds ratios (ORs) with corresponding 95% confidence intervals (CIs) for recurrence.\u003c/p\u003e \u003cp\u003eAll statistical tests were two-sided. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analyses were performed using R software (version 4.5.1; R Core Team 2025).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ea) Functional outcomes\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eOverall: women vs men\u003c/h2\u003e \u003cp\u003eAt baseline, quality of life and constipation were comparable between sexes, while fecal incontinence was more severe in women (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; \u003cem\u003eSupplementary Table S1\u003c/em\u003e). Surgery was associated with significant improvements in quality of life, constipation, and fecal incontinence at follow-up in both sexes (\u003cem\u003eSupplementary Table S1\u003c/em\u003e). Improvements did not differ statistically significantly between women and men at either follow-up interval, indicating broadly similar functional improvement across sexes (\u003cem\u003eSupplementary Table S1\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eStratified by operative approach: women vs men\u003c/h3\u003e\n\u003cp\u003eAfter stratification by abdominal versus perineal approach, there were no statistically significant sex differences in baseline functional measures or in change-from-baseline effects within either approach (\u003cem\u003eSupplementary Table S2\u003c/em\u003e). These subgroup comparisons should be interpreted cautiously for perineal repairs given the small male sample in perineal approach group.\u003c/p\u003e\n\u003ch3\u003eb) Recurrence rates\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOverall: women vs men\u003c/h2\u003e \u003cp\u003eOverall recurrence rates did not differ significantly by sex (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; \u003cem\u003eSupplementary Table S1\u003c/em\u003e). In exploratory univariate logistic regression, neither sex nor age demonstrated a statistically significant association with recurrence (\u003cem\u003eSupplementary Table S5\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStratified by operative approach: women vs men\u003c/h2\u003e \u003cp\u003eWithin both abdominal and perineal approaches, recurrence rates did not differ significantly between women and men (\u003cem\u003eSupplementary Table S3\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ec) Complications\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eOverall: women vs men\u003c/h2\u003e \u003cp\u003ePostoperative complications were uncommon and did not differ significantly by sex (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most of the complications were minor, according to Clavien-Dindo classification (\u003cem\u003eSupplementary Table S0\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStratified by operative approach: women vs men\u003c/h2\u003e \u003cp\u003eComplication rates remained low within both abdominal and perineal groups and did not demonstrate a statistically significant sex-specific pattern (\u003cem\u003eSupplementary Table S4\u003c/em\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics, operative approach, and outcomes by sex. Data are presented as median (IQR) for continuous variables and n (%) for categorical variables. P-values reflect between-sex comparisons at baseline or for categorical outcomes (Mann-Whitney U or Fisher\u0026rsquo;s exact test).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value (between sexes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics and operative approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach: abdominal, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (77.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach: perineal, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFunctional outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL preoperative, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL 1 year, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.5 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL 3 years, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation (CCCS) preoperative, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation (CCCS) 1 year, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation (CCCS) 3 years, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFecal incontinence (Wexner) preoperative, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFecal incontinence (Wexner) 1 year, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFecal incontinence (Wexner) 3 years, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny complication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S0.\u003c/b\u003e Complications\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImplied management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClavien-Dindo grade\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnastomotic leak with sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReoperation with stoma creation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper GI bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIa\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor anastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntibiotics alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound seroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBedside management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransferred to internal medicine, therapeutic anticoagulation; eventually death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMassive presacral plexus bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound hematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBedside management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinor suture line bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReoperation with resuturing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIb\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S1.\u003c/b\u003e Overall statistical comparisons (sex differences, paired changes)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eBetween-sex comparisons (overall)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline QoL (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline Constipation (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline Incontinence (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta QoL 1y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta QoL 3y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta Constipation 1y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta Constipation 3y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta Incontinence 1y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelta Incontinence 3y (Mann-Whitney)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence by sex (Fisher)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eWithin-patient paired comparisons (overall)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL: pre vs 1y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL: pre vs 3y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation: pre vs 1y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation: pre vs 3y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncontinence: pre vs 1y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncontinence: pre vs 3y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S2.\u003c/b\u003e Approach-stratified between-sex comparisons (p-values).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep (age)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep (QoL pre)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep (CCCS pre)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep (Wexner pre)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep (ΔQoL 1y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep (ΔQoL 3y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep (ΔCCCS 1y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep (ΔCCCS 3y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep (ΔWexner 1y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003ep (ΔWexner 3y)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperineal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S3.\u003c/b\u003e Recurrence by sex within operative approach.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen, n/N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen, n/N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value (Fisher)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9/70 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/14 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperineal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23/92 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/4 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S4.\u003c/b\u003e Any postoperative complication by sex within operative approach.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen, n/N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen, n/N (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value (Fisher)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3/70 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/14 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperineal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5/92 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0/4 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSupplementary Table S5.\u003c/b\u003e Exploratory univariate logistic regression for recurrence (odds ratios and 95% CIs).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabg\" border=\"1\"\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContrast (reference)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOdds ratio (OR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI (profile) - lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI (profile) - upper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI (Wald) - lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI (Wald) - upper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale vs Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2,322\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePer 1-year increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1,027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicate that recurrence rates for rectal prolapse are lower in men than in women; however, this difference did not reach statistical significance. While this disparity might initially be attributed to the surgical approach - given that the abdominal technique is associated with lower recurrence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] - the data suggests a more complex etiology. Although a higher proportion of male patients undergo abdominal surgery, the increased success rate cannot be explained by the surgical method alone. Notably, when comparing abdominal approaches across genders, the procedure yields superior outcomes in men compared to women; again the difference between sexes within either abdominal or perineal repairs is not statistically significant, indicating that any apparent sex-related advantage should be interpreted as descriptive rather than confirmatory.\u003c/p\u003e \u003cp\u003eThis reason is likely multifactorial. Male patients presenting with rectal prolapse (RP) tend to be younger, often correlating with a lower ASA physical status, superior muscle tone, and higher collagen quality [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, anatomical differences play a role - the narrower male pelvis may inherently provide more structural support, thereby decreasing the risk of recurrence. Notably, even the higher prevalence of manual work among men does not offset these protective physiological factors. Consequently, our study suggests that gender and surgical approach should be regarded as two independent variables contributing to the slightly lower recurrence rates observed in male RP repair.\u003c/p\u003e \u003cp\u003eHowever, it is important to note that recent literature presents conflicting evidence regarding specific techniques. According to a 2019 systematic review [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], VMR may actually be associated with higher recurrence rates in men than in women. The authors suggest that the narrow male pelvis may potentially impede surgical manipulation. This technical difficulty, particularly for less experienced surgeons, may ultimately compromise the efficacy of the repair and lead to higher failure rates.\u003c/p\u003e \u003cp\u003eRegarding quality of life and postoperative constipation, our study found no significant gender-based differences. This suggests that the resolution of constipation is secondary to a surgical approach rather than sex-specific factors. As highlighted in clinical guidance, VMR is typically favored in patients with obstructed defecation syndrome, whereas resection rectopexy is reserved for those with slow-transit constipation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Ultimately, appropriate preoperative evaluation and intraoperative decision-making serve as the primary drivers of success in achieving constipation relief, ensuring that the intervention is tailored to the patient\u0026rsquo;s specific pathophysiology rather than their gender.\u003c/p\u003e \u003cp\u003eA key differentiating patient-reported outcome measure between the genders is fecal incontinence (FI), which was more severe in women preoperatively. This difference likely reflects distinct underlying etiologies; in many elderly women, rectal prolapse (RP) is secondary to a chronically lax sphincter and a weakened pelvic floor. Conversely, in the majority of men, incontinence is most likely a secondary consequence of chronic sphincter stretching and pudendal nerve traction caused by the rectal prolapse (RP) itself [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consequently, one can argue, that FI remission is often complete in men once the primary driver - the prolapse - is surgically corrected. In women, however, postoperative continence often returns to the diminished baseline levels present prior to the onset of RP. It is important to emphasize that prolonged RP can induce irreversible FI even in patients with previously preserved continence. Therefore, surgical repair should not be excessively delayed [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother important point to consider is the sexual function prior to and following the surgical intervention. Historically, traditional teaching advocated perineal approach in men to preserve sexual function [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The rationale was that an abdominal approach may cause inadvertent injury to the hypogastric nerves, inferior hypogastric plexus, pelvic plexus, or periprostatic plexus during rectal mobilization. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, contemporary evidence has challenged this paradigm. Fagan et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] noted that there is insufficient high-quality data to recommend a perineal approach solely for the preservation of sexual function. In the present study, while a formal, validated sexual function assessment was not conducted, no patients reported de novo sexual dysfunction during follow-up, regardless of whether they underwent ventral mesh rectopexy (VMR) or resection rectopexy.\u003c/p\u003e \u003cp\u003ePostoperative complications were uncommon overall and did not differ significantly by sex, including after stratification by operative approach. Given the small male subgroup and low event counts, the analysis is best interpreted as reassuring but exploratory with respect to sex-specific complication risk.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eThis study is subject to several limitations. First, the data represent a retrospective, single-center experience involving a single surgical team, which may limit the generalizability of the results. Furthermore, treatment allocation was not randomized; the choice between a perineal or abdominal approach was based on patient comorbidities and surgical risk profile.\u003c/p\u003e \u003cp\u003eWhile the cohort includes a relatively small number of patients, this reflects the low epidemiological prevalence of rectal prolapse (especially in men). Additionally, the study population is exclusively of Polish ethnicity. This is a relevant factor, as Vogel et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] have demonstrated significant disparities in rectal prolapse occurrence across different ethnic groups.\u003c/p\u003e \u003cp\u003eTechnical variability must also be considered, as three different types of mesh were utilized across the study period. Finally, the recurrence rates may be underrated, because the recurrences may occur even after 10 years after the surgery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this single-center study, rectal prolapse repair was associated with improvements in quality of life, constipation, and fecal incontinence at 1 and 3 years. Although men presented at a younger age and exhibited a different baseline continence profile, postoperative functional gains, recurrence, and complication rates did not reach statistical difference between sexes, both overall and after stratification by operative approach. These findings support the continued use of established, risk-guided surgical algorithms in both sexes while emphasizing that the current evidence in men remains limited by small sample sizes. Larger multicenter studies are needed to clarify whether subtle sex-specific predictors of recurrence or functional recovery exist and to suggest any future sex-tailored management strategy.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003eNo funding was received to assist with the preparation of this manuscript. The authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePC collected the data and served as the primary surgeon. SR conceptualized the study as well as performed data extraction, conducted the formal analysis, and drafted the manuscript. PC validated the data and contributed to data interpretation. MK provided supervision. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank Grzegorz Rzadkowski for his assistance with the statistical analysis.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this published article. Further information can be obtained from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRiansuwan W, Hull TL, Bast J, Hammel JP, Church JM (2010) Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World J Surg 34(5):1116\u0026ndash;1122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-010-0429-0\u003c/span\u003e\u003cspan address=\"10.1007/s00268-010-0429-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBordeianou L, Paquette I, Johnson E, Holubar SD, Gaertner W, Feingold DL et al (2017) Clinical practice guidelines for the treatment of rectal prolapse. 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Dis Colon Rectum 48(6):1200\u0026ndash;1206. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10350-004-0948-6\u003c/span\u003e\u003cspan address=\"10.1007/s10350-004-0948-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Rectal prolapse, VMR, rectopexy, Altemeier, Delorme, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-8630421/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8630421/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eRectal prolapse is markedly less common in men than in women, yet both sexes are managed using the same surgical algorithms. The study evaluates sex-specific functional outcomes, recurrence, and complications following abdominal and perineal rectal prolapse repair.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective single-center cohort included adults undergoing full-thickness rectal prolapse surgery between 2013 and 2023 with 12- and 36-month follow-up. Quality of life (EQ-VAS), constipation (CCCS), and fecal incontinence (Wexner) were assessed preoperatively and postoperatively. Outcomes were compared between women and men overall and stratified by operative approach. Recurrence and complications (Clavien-Dindo) were analyzed using Fisher\u0026rsquo;s exact tests; exploratory univariate logistic regression was performed for recurrence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 180 patients were analyzed (162 women, 18 men). Men were younger and more often treated with an abdominal approach. Baseline fecal incontinence was more severe in women, while baseline quality of life and constipation were comparable. Surgery significantly improved all functional domains at 1 and 3 years (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Change-from-baseline effects did not differ significantly by sex, including within approach strategies. Recurrence and complication rates were low and did not differ significantly between sexes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFunctional improvement after rectal prolapse repair was substantial in both sexes, without statistically significant sex-specific differences in treatment effect, recurrence, or complications.\u003c/p\u003e","manuscriptTitle":"Sex-Specific Outcome Profiles in Abdominal and Perineal Rectal Prolapse Repair","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-25 10:17:05","doi":"10.21203/rs.3.rs-8630421/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T21:14:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T04:50:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T21:25:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21074106276641632548808797133044327398","date":"2026-01-27T20:30:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9516177882099187878295048854206769267","date":"2026-01-26T22:32:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T21:35:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134429624519760611555521343231634748059","date":"2026-01-22T18:16:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T09:58:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T02:58:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T02:56:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2026-01-18T09:36:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6ea6ca87-f652-4da6-84db-a4bd9993937d","owner":[],"postedDate":"January 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-29T20:38:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-25 10:17:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8630421","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8630421","identity":"rs-8630421","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}